Millions need family planning help, advocates say

The world is taking notice, but what's the best approach for birth control?

Women wait outside the only maternity hospital in Srinagar, India, on July 10, 2008, a day ahead of World Population Day. (Mukhtar Khan/Associated Press)

About 200 million women around the world desire access to and information about safe contraception but are unable to get it. And that lack of access contributes to the deaths of millions of mothers and babies — in pregnancy, during childbirth and beyond, according to the United Nations Population Fund (UNFPA).

"Family planning programs have a tremendous impact on the reduction of maternal mortality," Dr. Yves Bergevin, co-ordinator of the Thematic Fund for Maternal Health, which was initiated by the UNFPA, said in an interview with CBC.ca.

Aminata Niang, a mother of 10, slips a condom over a soda bottle during a gathering in Dakar, Senegal, in July 2001. (Christine Nesbitt/Associated Press)

Bergevin says improving family planning among developing countries, which was the theme of this year's World Population Day on July 11, will ultimately benefit human development — from reduced population growth to reduced dependence on fuel use to improved wealth for Third World countries.

There has been progress on that front recently.

Several advocates for Third World family planning say the global attitude toward helping women plan pregnancies appears to be undergoing a positive shift.

Dr. Lisa Avery, an obstetrician from the University of Manitoba who is an expert in Third World contraception, told CBC.ca that the first step occurred in 1994 when the United Nations International Conference on Population and Development placed sexual and reproductive health — and specifically family planning — on the international agenda.

Family planning facts

At least 200 million women worldwide desire access to family planning methods but are unable to do so because they do not have access to family planning services.

99 per cent of the world's unsafe abortions occur in developing countries.

The UNFPA found that women in only 14 of 88 impoverished nations have safe access to clinics that offer family planning services.

Birth control can prevent 2.7 million newborn deaths each year.

Fewer than five per cent of the poorest adolescents in the world use modern birth control methods such as the birth control pill or condoms.

More than six million infant and child deaths each year could be prevented if essential health services for mothers and children were improved.

One woman dies every minute during pregnancy worldwide.

One woman dies every eight minutes during an unsafe abortion.

In Uganda, the lifetime risk of dying in childbirth is one in eight, while in Canada it's one in 8,000.

Sources: UNFPA, the Lancet, Dr. Dorothy Shaw

And just last week, at the Group of Eight Summit, world leaders pledged to strengthen maternal and infant health care, including a pledge to better provide access to contraception.

That, Bergevin says, means the G8 leaders "recognized the importance of reproductive health for the first time being key to human development."

The crucial next step is whether the promise will be backed up with resources, advocates say. Currently, funding for reproductive health in developing nations is $500 million US, but Bergevin says the UNFPA is recommending it be boosted immediately to $1.2 billion US, and up to $1.5 billion by 2015.

Unfortunately, the opposite has been true in recent years, says Dr. Dorothy Shaw, president of the International Federation of Gynecologists and Obstetricians and a clinical professor at the University of British Columbia. She says that family planning funding decreased by 55 per cent between 1996 and 2003.

A question of how

Experts say most nations have at least limited access to and knowledge about some modern methods as well as traditional methods of birth control (i.e. rhythm method, abstinence).

In many regions, it's best to provide not only a clinic that is accessible for women and couples, but to have at least three different methods of birth control available to give women options, Bergevin says.

But what are the best methods to empower women to plan their families, given the limitations of access, funding and stubborn gender inequality issues?

Several forms of birth control are available, each with benefits and risks. There are also new methods, including:

The combined patch: This patch is worn for three weeks and removed for the fourth week. It's made up of a combination of estrogen and progesterone. Positives, Avery says, are that "there is no delay in the return of fertility," and that "it is one of the newer types of contraception available."

The female condom: Avery says it's essentially a latex pouch a woman can insert vaginally or anally. "If used correctly, it is fairly effective, with five out of 100 women experiencing a pregnancy," she says. As well, reproductive experts say, it can empower women by allowing them to assert some control over their reproductive rights during intercourse, and they can use it without seeing a doctor.

Depo provera injections: Bergevin says these can be very effective, as they prevent pregnancy for three months. And they're also great for women who may not feel comfortable discussing contraception with their male partners, or who may fear abuse because they are using birth control. He emphasizes, however, that the UNFPA tries to encourage open communication on contraception within couples as much as possible.

Making men a part of the picture

The involvement of men in the family planning process is the missing link in the chain, advocates say.

Much work is being done to involve men in family planning, from having them come to health clinics with their partners and being encouraged to talk about contraception, to providing them with positive male role models in the community, such as male nurses and doctors.

"The importance of involving men in family planning has been neglected until very recently [the past 10 to 15 years]," Avery says. "Yet the global experience … clearly shows that involving men in sexual and reproductive health issues can promote gender equity, is essential in order to decrease HIV/AIDS and other sexually transmitted infections and prevent unplanned or unwanted pregnancies."

New IUDs: Those in the field of reproductive rights say the IUD is generally one of the easiest and safest, as well as long-term, ways for women in developing countries to plan their families. Bergevin said while the IUD has had a bad rap in the West, there are many newer, safer alternatives on the market and they can be inserted and remain in a woman's uterus for up to five years, then safely removed if she chooses to have more children Newest options include the copper-bearing IUD, a "small, flexible plastic" inserted into the uterus that can prevent pregnancy up to 10 years, says the UNFPA's website. The Levonorgestrel IUD is a T-shaped plastic device, inserted through the uterus, that can prevent pregnancy for five years, the UNFPA says. Both methods are reversible.

More established methods of birth control are also available:

Condoms: Advocates say along with helping prevent unwanted pregnancy, condoms can dramatically decrease the risk of sexually transmitted infections, including HIV and AIDS. However, many men in developing nations are unwilling to use them because of the stigma that they decrease pleasure and indicate promiscuity.

"In general, many programs advocate the double protection method, which means that condoms should be used in addition to any other method of contraception in order to prevent both pregnancy and transmission of sexually transmitted infections, including HIV and AIDS," Avery says.

Birth control pills: While the pill can be a good option, buying pills and taking them each month can be costly. Bergevin says that issue is addressed this way: in the poorest communities, it would be offered free. In semi-poor areas, the pill might be heavily subsidized (say 75 per cent), but individuals would pay the rest. That way, he said, they take a portion of responsibility in their own family planning.

Rhythm, abstinence, withdrawal before ejaculation: Most advocates say it is unrealistic to expect couples to abstain from sex in order to plan their families. The reality is these types of traditional methods don't have great success in helping women avoid pregnancy. Also, Avery notes that in many developing countries, a woman's value in society is determined by her ability to reproduce, so she may choose not to use birth control as a result. But women who are not willing, for religious or moral reasons, to use modern birth control may rely on the rhythm method. This technique relies on a calendar of the women's menstrual cycle to determine periods of higher and lower fertility.

CycleBeads: Developed in the United States, this method is being used in some countries, such as Senegal. A ring of beads comes in different colours and there are 32 in all, representing each day of a woman's menstrual cycle. By moving a rubber band on the ring from one bead to the next each day, women are able to calculate their most fertile times. While this can help give women some control over their fertility and can be a method used by females not wanting to use modern contraception such as the birth control pill or IUD, it is dependent on the male partner respecting the woman's wishes not to have intercourse on days she may become pregnant. Reproductive experts say men may not want to abstain from sex on these days. "It's not really a very effective method," Bergevin says.

Sterilization and abortion: Numerous aid organizations, including UNFPA, do not advocate abortion or sterilization as a form of birth control. For one, it can be difficult to obtain a safe abortion in many developing nations, causing a great risk to women's lives. Unsafe abortions cause the deaths of 67,000 women annually, Avery says. In terms of sterilization, most say it shouldn't be used by very young women. But Shaw says that in some countries, women as young as 15 to 19 want to be sterilized, because they've already had three or four children, and that number increases dramatically as they reach 25 to 30. "It is really quite remarkable, when you consider that demand exists," she says.